Provider Demographics
NPI:1790838175
Name:WATERMAN DERMATOLOGY, PA
Entity Type:Organization
Organization Name:WATERMAN DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-473-2078
Mailing Address - Street 1:600 S PINE ISLAND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3166
Mailing Address - Country:US
Mailing Address - Phone:954-473-2078
Mailing Address - Fax:
Practice Address - Street 1:600 S PINE ISLAND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3166
Practice Address - Country:US
Practice Address - Phone:954-473-2078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1982632527OtherTYPE I NPI NUMBER
FL1982632527OtherTYPE I NPI NUMBER
FL80306Medicare ID - Type UnspecifiedMEDICARE NUMBER